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Hilliard Law
Opioids NAS Survey
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CaseID
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Case Type
First Name
Last Name
PERSONAL INFORMATION OF NAS CLAIMANT AND HIS/HER REPRESENTATIVE
SECTION 1: Fill out the information of the NAS child below:
NAS Child's Name
NAS Child's Date of Birth
MM slash DD slash YYYY
NAS Child's Address (street address, city, state, zip)
NAS Child's Full Social Security Number
MEDICAL PROVIDER INFORMATION
SECTION 3.A.: This section concerns licensed medical providers who have diagnosed the NAS Child with any medical, physical, cognitive or emotional condition resulting from his/her intrauterine exposure to opioids or opioid replacement or treatment medication(s). The diagnoses may include, but are not limited to, the condition known as neonatal abstinence syndrome (“NAS”). Fill out and provide the following information, if known:
NAS Medical Provider Information: (Name, Address, City, State, Zip, Date of Diagnosis)
SECTION 3.B: Even if you do not know the information sought in Section 3.A, please include with your submission of this Claim Form Competent Evidence that a licensed medical provider has diagnosed the NAS PI Claimant with any medical, physical, cognitive or emotional condition resulting from the NAS Child’s intrauterine exposure to opioids or opioid replacement or treatment medication(s).
Was the NAS Child born in a medical facility? If so:
Select
Yes
No
Name of Facility where the NAS Child was born
Location (city and state) where the NAS Child was born
Medical Liens
SECTION 4.A: Did any insurance company pay for medical treatment for the NAS Child's opioid-related injuries?
Select
Yes
No
SIGNATURE INFORMATION (You must complete this Part Five regardless of your elections above)
NAS Child's Name
NAS Child's Email (if any)
NAS Child's Phone Number (If any)
Your Name
Your Email
Your Phone Number
HEIRSHIP DECLARATION / SWORN DECLARATION ( SIGNATORY IS EXECUTOR UNDER DECEDENT’S LAST WILL AND TESTAMENT)
I. DECEDENT (DECEASED) INFORMATION
Name
Social Security Number
Date of Death
MM slash DD slash YYYY
Residence/Legal Domicile Address at Time of Death (street address, city, state, zip)
II. PI CLAIMANT INFORMATION
Your Name
Your Full Social Security Number
Your Address (street address, city, state, zip)
Your Relationship to Decedent
Basis of Your Authority to Act for the Decedent
List here and attach copies of all document(s) evidencing the basis for your authority (for example, Last will and Testament)
Basis for authority documentation
Drop files here or
Select files
Max. file size: 32 MB.
III. HEIRS AND BENEFICIARIES OF DECEDENT
Use the space below to identify the name and address of all persons who may have a legal right to share in any settlement payment on behalf of the claim of the Decedent. Also, state if and how you notified these persons of the settlement, or the reason they cannot be notified.
Name and Information (street address, city, state, zip)
List here and attach copies of all document(s) evidencing the basis for your authority (for example, a copy of the intestate statute of the state or domicile of the Deceased Claimant at the time of his or her death.
Basis for your authority documents
Drop files here or
Select files
Max. file size: 32 MB.